Face Doctors

Hair Loss Online Consultation

This is a quick 3 minute validated questionnaire to identify and help both men and women who have a problem with Hair Loss.
Treatments are available to help you with this condition.

These Online Tests are simple questionnaires that are submitted to our Doctors to see if Face Doctors has a solution that is right for you. They are obligation free and absolutely confidential. Our Doctors will respond within 24 hours to your submission from your given email address.

Please note this treatment is only available at our Remuera Clinic.

How did you hear about this site?

If Other please specify:

First Name

Last Name

Age

Phone Number

Email

Gender

Male Female Other

If Other please specify:

Address

.

When did you start losing your hair?

Has it worsened recently? Yes or no

Is your hair loss

Diffuse Thinning Scattered Patchy Other

Please Explain:

Do you have a family history of hair loss? *

Yes No

If so, who:

Which hair loss type do you have? Male Norwood Scale. Female Ludwig Scale. See bottom of page.

Describe your general health

Good Average Poor

Please explain in more depth:

Serious illness past few years? Please describe. Type Nil if none.

Please explain further if you have clicked any of the above.

Do any of the following apply?

If you clicked any of the above, please explain. Please advise what contraception you are on

List all current medications. Type Nil if none.

List medicines when hair started falling out. For example antihistamines, cholesterol meds. Type Nil if none

Allergies to medicines or other. Type Nil if none

Dietary considerations. Tick any that apply

Please explain further if you have ticked any above

Are you taking Vitamins, Herbal medicines or performance enhancing drugs, steroids? Type Nil if none.

Do you exercise?

Yes No

If yes, how many times a week

Do you smoke?

Yes No

If yes. How many per day and for how long

How often is your hair chemically processed or straightened? Type Nil if none

If other please explian

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Norwood Classification Scale

Your personal details will remain confidential and not disclosed to any third parties. You have the right to view, change or delete this information on request. This questionnaire is not comprehensive, and does not replace a full history and physical examination and further information may be necessary on follow-up. Due diligence will be exercised for making a thorough assessment.

Please note this does not confirm your booking. We will get in touch with you to confirm your appointment time.
By submitting this form you will be signed up to the Face Doctors Clinic Newsletter. We respect your privacy and you can unsubscribe at anytime.

Please note we have allocated client parking, all unauthorized vehicles may be clamped or towed at owners expense. Clamping proceeds will be donated to monthly charity of our choice.

Hair Loss Online Consultation

Hair Loss Online Consultation

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